Mike DeWine, GovernorLori Criss,, Director

a set of guidelines or rules that determine a course of action.

series of actions conducted in a certain order or manner.

Mike DeWine, GovernorLori Criss, Director

Mike DeWine, GovernorLori Criss, Director

Mike DeWine, GovernorLori Criss, Director

“Policy” Guiding principle “What” and/or “Why”

“Procedure” or “Plan” Step-by-step instructions How we accomplish “How”, “When”, “Who”, sometimes “What”

• Guide day-to-day or emergency operations

• Set clear expectations

• Resident Policies

• Staff Policies and Procedures

Don’t I have to be a professional policy writer to

write policies, procedures, or plans?

Slides throughout this presentation will include tips, suggestions, ideas regarding content in policies, procedures and plans.

There may be other elements YOU should include in YOUR facility’s policies, procedures and plans.

Some may not be appropriate for YOUR facility.

You do not want this work to be only about meeting regulations.

The goal is to create a safer environment, provide clear direction to staff, and reduce risk to residents, staff and owners.

Do not develop these documents, then forget about them. Keep them relevant. Update as needed. Share updates with staff, and residents as applicable.

Mike DeWine, GovernorLori Criss, Director

(I) Each facility shall have written emergency evacuation plan drawings showing routes to exits. The evacuation plan shall be legible, explained to each resident, and shall be posted, at a minimum, on each floor, in highly visible locations throughout the facility.

The plan should include arrows or other ways clearly showing the routes to each exit.

Plan must be explained to each resident- at admission or if there are changes to the plan- document it was explained on resident agreement or other form

Plan shall be posted, at a minimum, on each floor- this includes the basement or attic

Highly visible throughout the facility – not behind doors, papers on the bulletin board, etc.

(J) Each facility shall hold and provide documentation of an evacuation drill at least quarterly on each shift for all staff and residents. Drills shall be conducted at different and varying times of day and night, and shall be conducted utilizing different exit routes.

Written log of date of evacuation drills- month day and year

Documentation of staff and residents present at each drill

Documentation of time of day or night- AM or PM

Documentation of routes used to exit- front door, back door, etc.

(K) Each facility shall establish a disaster plan appropriate to the facility's location, which includes contingencies for such items as the loss of utility service or the immediate evacuation of residents. The facility shall determine the requirements for training and disaster drills based on the facility's disaster plan, except fire evacuation drills, and shall document the requirements and provision of training and drills.

Each facility shall establish a disaster plan appropriate to the facility's location

Include fire, tornado, other as applicable, e.g. flood or nuclear power plant

If you have more than one facility- need one for each if they are in different locations

Plan is specific to the facility location- ex. near a river or creek that floods, nuclear plant, city vs rural, etc.

Plan is specific to staffing

Plan is specific to type of residents

The plan shall include contingencies for such items as the loss of utility service – what will you do when there is loss of electric, gas or water?

The immediate evacuation of residents- how will you evacuate, where will you meet to ensure everyone is safe, where will residents go if the house is not safe or inhabitable? What will you do or who will you call? Do you have residents who need assistance?

(4) In a class two or three facility at least one staff person shall be available on or off the premises to residents twenty-four hours per day. In the event that no staff person is on the premises, residents shall be informed of how to locate staff, who shall be promptly available to provide appropriate and needed assistance to residents.

Residents need to know procedure to locate staff immediately

Staff need to be available promptly to come to the facility

(6) In the event that no staff person is on the premises, the operator shall be responsible for ascertaining and ensuring that each resident is capable of self-preservation, and is knowledgeable about obtaining emergency assistance

Operator ensures residents are trained in DisasterPlan/Evacuation Procedures at time of admission and documented on resident agreement

Operator ensures that residents are capable of self preservation-this means being able to leave the facility on their own without assistance

(7) Ensure that no resident shall be required or designated to supervise other residents, provide for the personal care or mental health service needs of other residents, or supervise any aspect of the operation or management of the facility

Residents cannot be assigned to supervise or assist other residents in the evacuation of the facility

Residents cannot be assigned to be responsible to execute the disaster plan- this is staff responsibility

Where is(are) the safe spot(s) in YOUR facility When do residents and staff need to go to the safe spot

(tornado watch, tornado warning) Who is responsible to assure residents go to the safe

spot (24 hour staffing, are residents mobile, residents’ cognitive awareness including effect of medication)

What supplies needs to be brought to the safe spot, under what circumstances, and who is responsible to bring the supplies

What about when staff are out of the facility with residents, e.g. driving to an appointment

How long do residents and staff stay in the safe spot

http://www.spc.noaa.gov/faq/tornado/safety.html

https://www.fema.gov/media-library-data/1409003506195-52740fd2983079a211d041f7aea6b85d/how_to_prepare_tornado_033014_508.pdf

http://www.spc.noaa.gov/faq/tornado/safety.htmlhttps://www.fema.gov/media-library-data/1409003506195-52740fd2983079a211d041f7aea6b85d/how_to_prepare_tornado_033014_508.pdf

What are the primary and secondary exits in each area Who is responsible to call 911/fire department?

When? Who is responsible to assure residents exit the facility?

(24 hour staffing, are residents mobile, residents’ cognitive awareness including effect of medication)

Where do residents and staff go outside, where should residents and staff meet

https://www.travelers.com/resources/home/fire-safety/how-to-create-a-fire-evacuation-plan

https://www.travelers.com/resources/home/fire-safety/how-to-create-a-fire-evacuation-plan

The Rehabilitation Center at Hollywood Hills What if tornado, fire, flood, ice storm damage, makes facility

or a portion of the facility unsafe to live in for a period of time Immediate needs – safety first Who can assist (depending on the nature of the disaster, local

resources may be initially limited) Where do you move residents, who is responsible for moving

residents Who is responsible for notifying family, guardians, case

managers

Note: There is a requirement to submit a reportable incident to MHAS if residents need to spend at least one night elsewhere.

What utility How long is the utility anticipated to be out (does your

local utility provider offer text alerts) What is it used for (Heat, lighting, cooking, water) What time of year is it (no heat or furnace when

high/low temperature is 75/55 looks different than when it is 95/80 or 35/15)

Who can assist How do you preserve what resources you have

Mike DeWine, GovernorLori Criss, Director

(I) The facility shall maintain room temperatures appropriate for the comfort and health of residents but shall not exceed eighty-one degrees Fahrenheit.

(K) The facility shall develop a plan for responding to temperatures outside of the range specified in paragraph (I) of this rule. The plan shall include measures to be taken to assure the health, safety, and comfort of residents.

Monitoring Temperature

Monitoring residents

Use of air conditioners, fans, cold water, etc.

Power/Utility outage- short term vs long term

Contacting case manager/guardian

Plan to go to another location- temporary

Utilize Disaster Plan for relocation – long term

Mike DeWine, GovernorLori Criss, Director

(A) The residential facility shall assure appropriate policies and procedures regarding the administration and management of the facility including compliance with the requirements for licensure. This responsibility shall also include, but may not be limited to:(1) Arranging for necessary permits and inspections, and paying all fees and costs associated with inspections; (2) Daily monitoring and supervising staff to assure acceptable performance of assigned job duties and compliance with the requirements for licensure; (3) Participating in an appropriate and cooperative working relationship with the board or the department;

(A) The residential facility shall assure appropriate polices and procedures regarding the administration and management of the facility including compliance with the requirements for licensure. This responsibility shall also include, but may not be limited to:

(4) Reporting to the department any change regarding facility operation or use that relates to the requirements for licensure; (5) For a class two or three facility, reporting to the department a current emergency contact telephone number for the operator and manager. (6) Securing appropriate, alternative responsibility for the operation and staffing of the facility for planned or unplanned staff/operator absence; (7) Consistently maintaining the finances necessary for the stable and safe operation of the facility;

(A) The residential facility shall assure appropriate polices and procedures regarding the administration and management of the facility including compliance with the requirements for licensure. This responsibility shall also include, but may not be limited to:

(8) Maintaining a stable and supportive environment for residents of the facility, through respect for the rights of residents, as well as sensitivity and responsiveness to resident's needs, preferences and culturally competent services and care; and (9) Knowledge of and compliance with federal, state, and local laws concerning the ownership and operation of the facility, including, but not limited to zoning requirements or equal opportunity employment practices .

Not asked for on application Does NOT require a specific written policy, procedure or plan to

address the elements in (A)(1) – (A)(9) Addresses need to have policies and procedures for your

facility, i.e. how you run your business, staff expectations, who is responsible to assure certain tasks are completed.

If MHAS finds non-compliance in a certain related areas, do not be surprised if you there is discussion or findings in this area. Example: No staff in facility when facility is required to have staff. Explanation provided to MHAS is that the 2nd shift staff had a flat tire on the way to work, and the 1st shift staff left at the end of his/her shift. Q: What is the facility’s policy on staff absences, staff leaving when replacement staff do not show up, etc.?

The rules that apply to residential care facilities are in rules 5122-30 and were most recently updated 1/1/18.

The rules are located online at https://mha.ohio.gov/About-us/Regulation/Rules#2308586-licensure-of-residential-facilities-5122-30

https://mha.ohio.gov/About-us/Regulation/Rules#2308586-licensure-of-residential-facilities-5122-30

Sample forms are located online at https://mha.ohio.gov/Health-Professionals/Licensure-and-Certification/Residential-Programs-non-SUD#153797-sample-forms

https://mha.ohio.gov/Health-Professionals/Licensure-and-Certification/Residential-Programs-non-SUD#153797-sample-forms

Webinars on the rule requirements are available free of charge online and can be accessed here:

https://mha.ohio.gov/Health-Professionals/Licensure-and-Certification/LC-Webinars-and-Trainings#152678-residential-facilities-non-substance-use-disorder

https://mha.ohio.gov/Health-Professionals/Licensure-and-Certification/LC-Webinars-and-Trainings#152678-residential-facilities-non-substance-use-disorder

Applications are available only online and can be accessed here:

https://mha.ohio.gov/Health-Professionals/Licensure-and-Certification/Residential-Programs-non-SUD

https://mha.ohio.gov/Health-Professionals/Licensure-and-Certification/Residential-Programs-non-SUD

If you are currently licensed or in the process of being licensed, contact your assigned Behavioral Health Surveyor.

How can I find out who my Behavioral Health Surveyor is and how to contact him or her? Email Licensure and Certification staff atLicCert@mha.ohio.gov.

If you are not yet licensed, email Licensure and Certification staff at LicCert@mha.ohio.gov.

mailto:LicCert@mha.ohio.govmailto:LicCert@mha.ohio.gov

�Class 2 Residential Care Facilities�Policies, Procedures & Plans��Disaster Plan�Excessive Temperature Policy and Procedures����Donna M. Sabo, Supervisor�Licensure and Certification�Policy: a set of guidelines or rules that determine a course of action.��Procedure: series of actions conducted in a certain order or manner.�TJ Maxx Return Policy��If you're not satisfied with your purchase, return the merchandise accompanied by a register receipt within 30 days of purchase, for an exchange or refund. A 10 day period is required for a cash refund on check purchases. Returns with receipts over 30 days or without a receipt will receive store credit only.�Return Procedure:��Take merchandise with the receipt to the store within 30 days of purchase�Check receipt to verify date of purchase to determine refund status�No Receipt or over 30 days will be given store credit �Items paid by check will require a 10 day waiting period to receive cash refund���Slide Number 5Slide Number 6Slide Number 7Slide Number 8Slide Number 95122-30-12�Safety��Slide Number 11Slide Number 12Slide Number 13Slide Number 14Slide Number 15Slide Number 16Slide Number 17Slide Number 18Slide Number 19Slide Number 20Slide Number 21Slide Number 22Slide Number 23Slide Number 24Slide Number 25Slide Number 265122-30-15 Housekeeping and �Property Maintenance�(Excessive Indoor Temperature Policy)�Slide Number 28Slide Number 29Slide Number 305122-30-19 Facility administration and managementSlide Number 32Slide Number 33Slide Number 34Slide Number 35Slide Number 36Slide Number 37Slide Number 38Slide Number 39Slide Number 40